Paramedic role in emergency mental healthcare

Historically, paramedics have focused on emergency treatment and transport for acute physical conditions. However, their roles have significantly diversified, with paramedics now undertaking various roles such as health promotion, chronic disease management, minor injury care, community paramedicine, and supporting emergency department operations (Acker et al, 2014; Drennan et al, 2014). One major expansion is the integration of paramedics into mental health care.

The expanding involvement of paramedics in mental healthcare can be seen as part of a broader trend towards diversifying and specialising their roles beyond traditional emergency response (Acker et al, 2014; Abrashkin et al, 2021). As mental health crises and suicides continue to be significant public health challenges (World Health Organization (WHO), 2021), there is growing recognition of the need for more effective and coordinated emergency response services. Paramedics—often the first point of contact for individuals in crisis—are well-positioned to play a vital role in improving the accessibility, timeliness, and appropriateness of mental healthcare.

However, these enhanced responsibilities also present significant challenges and considerations for paramedics and the wider health system. These include the need for specialised training, supportive organisational structures, and close collaboration with mental health services (Gregg et al, 2019; Ford-Jones and Daly, 2022). Furthermore, the expanding scope of paramedic practice raises questions about professional boundaries, medicolegal risks, and the potential impact on the wellbeing of paramedics themselves (Rees et al, 2015).

Dedicated mental health paramedic roles have emerged in some jurisdictions. Mental health paramedics undertake emergency psychiatric assessments, mental health crisis responses, involuntary detention and transport to psychiatric facilities (McCann et al, 2018a). For example, the Mental Health and Paramedic (MHaP) programme in Victoria, Australia, established in 2015, employs a collaborative model, in which specially-trained paramedics and mental health nurses work together to provide on-scene assessment, treatment and referral for individuals experiencing mental health crises. A study by Roggenkamp et al (2018) found that the MHaP programme was associated with reduced emergency department transports and improved patient outcomes, highlighting the potential benefits of this collaborative approach.

In addition, generalist paramedics are taking on greater mental health responsibilities within mainstream ambulance services, including responding to psychiatric emergencies, supporting police during mental health incidents and diverting patients to services (Gregg et al, 2019; Ford-Jones and Daly, 2022). These expanded roles have often developed informally in response to pressures on emergency services from rising mental health acuity and limited specialist resources.

Internationally, the provision of emergency mental healthcare by ambulance services varies. Some emergency medical services agencies have implemented specialised mental health response units in the United States that pair paramedics with mental health professionals (Gregg et al, 2019; Lakey, 2022). Similarly, several states have introduced mental health emergency response teams in Australia, including paramedics working alongside police and mental health clinicians to provide coordinated care for individuals in crisis (Roggenkamp et al, 2018).

In the UK, the NHS Long Term Plan set out a vision for all ambulance services to have mental health professionals working within their clinical hub (NHS England, 2019). An innovative example is the Integrated Access Partnership (IAP) in South West England, which provides coordinated care across ambulance, mental health, and primary care services to provide specialist mental health triage, assessment, and care (NHS Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), 2024). The IAP has significantly reduced emergency department (ED) presentations, with over 99% of mental health-related calls to the NHS 111 service being managed without needing an ED visit (AWP, 2024). Similarly, some UK ambulance trusts, such as the Yorkshire Ambulance Service, have implemented mental health response cars staffed by paramedics and mental health nurses to provide on-scene assessment and referral (Yorkshire Ambulance Service NHS Trust, 2021).

However, the availability and consistency of mental health emergency care provided by ambulance services across the UK remain variable. A Care Quality Commission (2015) report, updated in 2022, highlighted the need for better integration between ambulance and mental health services and increased mental health training for paramedics. While there is growing recognition of the role paramedics can play in responding to mental health emergencies, the extent of their involvement varies internationally.

This article will evaluate the opportunities and challenges raised by paramedics assuming enhanced mental health roles by drawing upon selected relevant literature and exploring key issues. While not a systematic review, the article aims to critically analyse the topic by examining pertinent research findings, policy documents, and practice examples. The discussion will identify central themes, considerations, and implications for expanding paramedics' involvement in mental healthcare delivery.

Rationale for enhanced roles

Several factors have driven the increase in paramedics undertaking mental healthcare responsibilities.

First is rising demand. Mental health calls are increasingly prominent in ambulance service caseloads. Data from several countries indicate mental health cases account for around 10% of ambulance call-outs, often involving crises (Roggenkamp et al, 2018; Wadsworth et al, 2023). With the rising prevalence of mental health conditions, demand for paramedic first responders will likely grow.

Second are service pressures. Specialist mental health services often struggle to meet urgent response time targets. Long emergency department wait times for mental health patients can worsen outcomes and experiences (Nicks and Manthey, 2012). Using paramedics may allow quicker crisis intervention.

Policy shifts have had effects. Initiatives promoting community-based mental healthcare have required care pathways to be reconfigured, with paramedics well placed to provide rapid access to assessment and ongoing support through strong links to other emergency services (Jensen et al, 2013).

Finally, diverting mental health cases to specialist community care rather than expensive hospital admission may reduce costs. Specialist paramedic roles may also limit police time required for mental health incidents (de Jong et al, 2022).

There are, therefore, compelling drivers encouraging enhanced paramedic involvement in mental healthcare. Potential benefits and inherent challenges must be weighed up when considering how this goal can be best achieved.

Potential benefits

Several potential advantages of greater paramedic involvement in mental healthcare have been proposed.

One is improving access to timely mental health crisis care. As first responders, paramedics can provide prompt specialist assessment and intervention, reducing the risks associated with prolonged emergencies (Shaban, 2005). Having paramedics integrated into mental health crisis response services could also help bridge the gaps between mental health, emergency and police services. Collaboration can enhance communication and coordination across these sectors (Jensen et al, 2013).

In addition, the familiarity and accessibility of ambulance services may have advantages in terms of increased accessibility and reduced stigma, especially for marginalised groups (McCann et al, 2018b). The public is familiar with accessing ambulance services, which may be less intimidating and more approachable for those with mental health needs than formal psychiatric services. Furthermore, paramedics attending incidents in community settings can facilitate early intervention for patients unwilling or unable to travel to hospitals.

Paramedics may also contribute through triage and diversion to appropriate care, bypassing hospital emergency departments, which are often unsuitable places for mental health needs (Roggenkamp et al, 2018). Recent evidence suggests that paramedic involvement in mental health crisis response can help to reduce the pressure on police resources. For example, a study by Marcus and Stergiopoulos (2022) found that introducing a co-responder model, where paramedics and mental health clinicians worked alongside police officers, significantly reduced the time police spent on mental health-related calls. The model also improved patient outcomes and increased the likelihood of individuals being referred to appropriate community-based services rather than being transported to hospital emergency departments or taken into police custody.

Recent research suggests that specialist mental health paramedics, with advanced training and expertise, can provide higher quality mental health assessments and care than generalist paramedics or police officers. A study by McCann et al (2018a) found that patients assessed by mental health paramedics were more likely to receive a comprehensive mental health assessment, be referred to appropriate community-based services, and have lower rates of emergency department presentation and hospital admission compared with those assessed by generalist paramedics or police.

Furthermore, a systematic review by Emond et al (2019) concluded that specialised mental health training improved patient outcomes, increased confidence and competence among paramedics, and better collaboration with other mental health service providers. These findings highlight the potential benefits of having dedicated mental health paramedics within emergency response systems.

While these studies provide promising evidence for the benefits of specialist mental health paramedics, it is important to note that much of the research in this area has been conducted on a relatively small scale or relies on self-reported data. Continued evaluation using robust, large-scale research designs is needed to substantiate these findings further and explore the long-term impacts of specialised mental health paramedic roles.

Moreover, it is crucial to recognise that paramedics can play a valuable role in improving access to prompt mental health assessment and crisis intervention. However, their involvement should not be seen as a substitute for comprehensive, high-quality specialist mental health services. Paramedic care is just one component of a coordinated system of mental health support, and ongoing investment in community-based treatment, rehabilitation, and recovery services remains essential.

A key issue is how paramedic assessment and short-term crisis response can be effectively integrated with ongoing care. Ensuring smooth transitions and continuity of care between paramedic interventions and longer-term mental health support is a significant challenge that requires close collaboration between emergency services, mental health providers, and community organisations.

Barriers

While opportunities exist, several obstacles to expanded paramedic mental health roles have been highlighted. One fundamental issue is the limited mental health training in core paramedic education. Studies have shown mental health training within the paramedic curricula to be lacking in quality and quantity, with as little as 4% of the curricula devoted to mental illness (Wadsworth et al, 2023). Paramedics themselves continue to identify a lack of knowledge and confidence as critical barriers to taking on greater mental health responsibilities. A recent qualitative study by Rees et al (2018) explored the experiences and perceptions of paramedics in Ireland regarding their role in mental healthcare. Participants reported feeling underprepared and lacking the necessary skills to effectively manage mental health crises, citing limited mental health education and training as significant contributors to their lack of confidence.

Similarly, a study conducted by McCann et al (2018) that explored paramedic perceptions on their scope of practice incorporating mental health patients concluded that better undergraduate and in-service mental health education was required to address concerns about incorporating mental health scope of practice. These findings highlight the ongoing need for improved mental health education and support for paramedics to confidently and effectively take on expanded roles in mental healthcare delivery.

This suggests that substantial investment in specialised skills training is required to develop paramedics' capabilities in assessing and managing mental health patients.

In the UK, the current standard for paramedic education is a 3-year Bachelor of Science (BSc) degree in Paramedic Science, including academic coursework and clinical placements (College of Paramedics, 2019a). However, the specific content and duration of mental health education in these programmes can vary considerably between universities. A review of paramedic curricula by the College of Paramedics (2019a) found that while all programmes included some mental health content, the depth and focus of this education varied widely, with some programmes dedicating as little as 5 hours to mental health-specific topics.

Post-registration training opportunities in mental health for paramedics are also limited. The College of Paramedics (2019b) offers a short online course in mental health first aid, but more comprehensive, specialised training programmes are not widely available. Some ambulance services have developed their own in-house mental health training for paramedics, but these programmes are not standardised across the country (National Institute for Health and Care Excellence (NICE), 2017).

Another clear challenge is role ambiguity and variability in the duties assigned to paramedics around mental health. Clear protocols on responsibilities, scope of practice and inter-agency collaboration are needed (Shaban, 2005) but are often lacking. Similarly, ensuring continuity of care can be problematic when paramedics traditionally provide only an initial emergency response before transferring patients to hospital or specialist services (Ebben et al, 2017). Developing better referral pathways and links with ongoing community mental health treatment is critical to avoid fragmentation.

Some mental health professionals and user groups have expressed concerns about increased paramedic involvement, including risks of greater coercion and mental distress being over-medicalised (Rees et al, 2017). There are also fears that paramedic involvement could lead to ‘wide screening’ of mental health problems, leading to unnecessary treatment or erosion of specialised care. These concerns reflect a broader debate about the potential unintended consequences of expanding the role of paramedics in mental healthcare. Some worry that tasking paramedics with identifying mental health problems, even when they are not the primary reason for the emergency call, could lead to overdiagnosis and overtreatment (Rees et al, 2018). This phenomenon, known as ‘diagnostic overshadowing,’ occurs when physical symptoms are misattributed to mental health conditions, leading to inappropriate care and potentially delaying the detection of underlying medical issues (Shefer et al, 2014).

Furthermore, there are fears that an increased focus on mental health within paramedic practice could undermine the availability and quality of specialised mental health services. If paramedics are expected to take on a more significant role in mental health assessment and intervention, there is a risk that this could be seen as a substitute for investment in dedicated mental health resources, leading to a gradual erosion of specialised care (Rees et al, 2018). Meaningful engagement to understand and address these concerns will be critical for expanding roles.

Another concern is that providing improved access to mental healthcare through paramedic services may inadvertently reinforce inappropriate health-seeking behaviours, particularly among individuals with complex emotional needs or personality disorders such as borderline personality disorder (BPD) or emotionally unstable personality disorder (EUPD). These individuals often experience frequent crises and may engage in repeated, high-risk behaviours that lead to frequent emergency service use (Willis et al, 2020).

While timely access to care is essential, there is a risk that a more responsive and accessible paramedic service could unintentionally encourage reliance on emergency services as a primary coping mechanism rather than promoting engagement with longer-term, community-based support (Rees et al, 2015. This could lead to a ‘revolving door’ phenomenon, where individuals cycle through emergency services without addressing underlying issues or developing more adaptive coping strategies (Vandyk et al, 2018).

To mitigate these risks, paramedics must receive adequate training in recognising and managing complex emotional needs and personality disorders. Additionally, close collaboration with mental health services is essential to ensure that individuals are connected with appropriate ongoing care and support rather than relying solely on emergency interventions (Willis et al, 2020).

It is also essential to consider the legal and ethical implications of expanding paramedics' roles in mental healthcare, particularly in relation to involuntary assessment and treatment. In many jurisdictions, police have the authority to detain individuals under mental health legislation, and paramedics play a crucial role in assisting with the assessment and transportation of these individuals to a place of safety. For example, in England and Wales, police officers can use Section 136 of the Mental Health Act 1983 to remove a person from a public place to a place of safety if they appear to be suffering from a mental disorder and need immediate care or control [Mental Health Act, 1983]. In such cases, paramedics work closely with police to ensure the safe and appropriate transport of the individual to a designated place of safety, such as a hospital or specialised mental health facility (Chidgey et al, 2019).

However, there is ongoing debate about whether paramedics should be granted more extensive powers under mental health legislation. Some argue that enabling paramedics to initiate involuntary assessments and detentions could lead to more timely and appropriate interventions, reducing the burden on police resources (Emond et al, 2015). Others caution that expanding paramedics' authority in this area could lead to increased rates of involuntary treatment and potential infringements on individual rights (Rees et al, 2018).

In Australia, paramedics in some states have access to emergency detention powers for individuals experiencing mental health crises, allowing them to transport patients to a hospital for assessment without their consent (Bradbury et al, 2017). These powers have been controversial, with concerns about the lack of standardised training and protocols for paramedics in applying mental health legislation (Emond et al, 2019).

As the role of paramedics in mental healthcare evolves, any changes to their legal powers and responsibilities must be accompanied by comprehensive training, clear guidelines, and robust accountability mechanisms to ensure that the rights of individuals with mental health conditions are protected (Chidgey et al, 2019).

Finally, the cost implications of creating specialist paramedic positions or expanding training are unclear, and demonstrating cost-effectiveness will likely be necessary for policy support. Economic analysis of existing programmes is limited, making it difficult to define return on investment.

Key issues and controversies

Several issues have been contested in debates on enhanced paramedic mental health roles.

First is specialist versus generalist roles. Some argue all paramedics should receive mental health training to prevent two-tier services (Emond et al, 2019). Others favour specialist mental health paramedic roles to provide experts skilled in crisis intervention. Hybrid models with specialist support available to generalists are also proposed (Emond et al, 2019).

Next are role boundaries. Clarity is needed on where paramedic responsibilities begin and end. There are risks of paramedics being drawn into policing matters or acting as pseudo social workers if their roles are ill defined (Rees et al, 2015).

Finally, medicalisation and coercion need to be considered. Providing emergency response should not lead to the ‘psychiatrisation’ of social problems or increased coercion in mental health treatment (Emond et al, 2019). Safeguards must be in place.

These issues highlight the need for debate on where paramedics can add most value within local mental health systems. Stakeholders may have differing expectations regarding appropriate paramedic roles. Open discussion involving paramedics, mental health professionals, service users, police and policymakers is essential to build a shared understanding.

Discussion

This analysis indicates that while involving paramedics in mental healthcare could yield benefits, substantial barriers need to be addressed.

Investment in skills-based training is crucial to developing paramedics' capabilities in mental health risk assessment, crisis response, de-escalation techniques, mental health first aid and cultural competency (Lam et al, 2010; Wadsworth et al, 2023).

The proposed model for integrating paramedics into mental healthcare (Figure 1) highlights the key components and pathways from the initial emergency response to ongoing support and improved patient outcomes. The model emphasises the importance of collaboration between emergency services, mental health professionals, and community-based care providers to ensure that individuals experiencing a mental health crisis receive the most appropriate level of care and support.

Core competencies must cover practical areas such as communicating empathetically, engaging patients collaboratively, de-escalating aggression or agitation, assessing suicide risk, safely restraining and information sharing. Training should move beyond traditional didactic teaching to more interactive and experiential modalities like simulation exercises and scenario-based learning. Recent studies have highlighted the effectiveness of these approaches in enhancing paramedics' mental health knowledge, skills, and confidence (Bienstock et al, 2022).

Similarly, O'Brien et al (2013) found that simulation-based education effectively improved paramedics' knowledge, attitudes, and skills related to mental healthcare. These findings underscore the importance of incorporating simulation exercises and other interactive teaching methods into paramedic mental health education to better prepare them for the complex challenges they may face in the field. Ongoing supervision and access to specialist advice are also vital.

In addition to enhanced education, carefully delineating paramedic mental health roles via clear protocols is essential. These should cover practical responsibilities around assessment, referral, inter-agency collaboration and other duties developed collaboratively with mental health services and users (Jensen et al, 2013). Alignment with existing care pathways, service structures and regulatory frameworks needs to be considered; an example would be clarifying the interplay between mental health and mental capacity legislation related to paramedic practice. Clinical governance procedures must provide appropriate oversight.

While paramedics may conduct initial assessments, ongoing care should remain the responsibility of specialist mental health teams. High-quality referral pathways into continued community treatment are needed, facilitated through liaison roles or co-response models bringing paramedics and mental health staff together (Roggenkamp et al, 2018).

In England, while mental health conditions account for approximately 25–30% of the total disease burden, only around 13.6% of the NHS budget is allocated to mental health services (NHS England, 2019). This disparity suggests that many patients with mental health needs are likely to be managed in primary care settings, such as general practice, rather than being referred to specialist services.

A study by Ford et al (2016) found that only 24% of patients presenting to primary care with a mental health problem in the UK were referred to specialist mental health services within the first year of diagnosis. The majority of patients were managed within primary care, often with the support of medication and brief psychological interventions. These findings highlight the crucial role of primary care in managing mental health conditions and the need for paramedics to have strong links with general practitioners and community mental health teams to ensure continuity of care.

However, it is essential to note that the likelihood of referral to specialist services may vary depending on the severity and complexity of the patient's mental health needs, local service availability and referral pathways. Paramedics play a vital role in identifying patients requiring more intensive support and facilitating access to appropriate specialist care when needed.’

More research assessing mental health programmes involving paramedics is warranted. Studies should evaluate clinical outcomes, costs, service user experiences and impacts on local mental health systems using robust methods. Comparing outcomes across regions with varying models could help strengthen the evidence base. Qualitative research could provide valuable insights into how key stakeholders perceive enhanced roles.

Economic analysis is also essential. The case for funding specialist training and roles needs to show a clear return on investment, demonstrating cost savings from reduced hospital admissions and police time. Appropriate mental healthcare is a moral imperative, but cost constraints on health services necessitate evidence of affordability.

Paramedic mental health roles must be developed collaboratively with service users, who should be involved as equal partners (Bee et al, 2015). Recovery-oriented practice should be promoted over coercive models. Efforts to minimise stigma and increase social inclusion should be maintained. Listening to lived experience will ensure services stay responsive to patient needs and preferences.

Conclusion

In conclusion, with careful attention to education, clear role definition, robust interdisciplinary partnerships and strong governance, extending paramedic roles into mental healthcare could allow prompt, appropriate crisis response integrated with ongoing treatment.

Dedicated training investment, evidence-based service design and meaningful engagement with mental health professionals and users are vital to realising benefits while ensuring safety and quality. Role expansion also requires a nuanced understanding of where paramedics can add most value within the spectrum of mental health service provision.

Moving forward, it is essential to continue the dialogue and collaboration between paramedics, mental health professionals, service users, and other key stakeholders to refine and optimise the role of paramedics in mental healthcare delivery. This ongoing process should be informed by rigorous research, evaluation of existing programmes, and sharing of best practices across different jurisdictions. As the mental health needs of communities continue to evolve, so must paramedics' roles and capabilities to ensure they are well-equipped to provide timely, effective, and compassionate care to those in crisis.

Key Points

• Paramedic roles have expanded and now include greater involvement in mental healthcare

• Potential benefits of enhanced paramedic mental health roles include a more prompt access to crisis response, integration of emergency, police and mental health services, and more accessible care

• Significant challenges exist around limited mental health training for paramedics, role definition ambiguity, fragmentation and concerns from mental health professionals

• Evidence-based role development, investment in education, clear protocols, robust governance and interdisciplinary collaboration will be essential to realise benefits of greater paramedic involvement in mental healthcare while ensuring safety and quality

CPD Reflection Questions

• How could paramedics be better supported in your area to take on enhanced mental health responsibilities? What training, protocols or partnerships would be needed? Can you identify any potential risks or unintended consequences?

• How could paramedics, mental health professionals and service users work together in your context to co-design new crisis response roles or services? What would meaningful collaboration look like and how would governance work to provide oversight?

• If you were developing a specialist mental health paramedic role, what core capabilities and competencies would you want candidates to have? What training content would be essential?